3

plioric, lactic, and inosinic acids divide between them the Ibase existing there-viz., the potash,-so in the blood the sodais divided between the phosphoric and carbonic acids; andin this case, as in many other phenomena in the animal body,there appears to be an exertion of a:finit·, without the powerof combination. It is more than probable that the studyof such phenomena may lead to very important results inpathology and therapeutics.

The chloride of sodium, or common salt, which forms solarge a proportion of the ash of blood, has doubtless manyimportant uses in the animal economy, of which we are atpresent ignorant. Without a due supply, the system becomesdiseased, and hence the instinctive desire for it possessedboth by man and many other animals. As we have seen thatthe phosphate of soda is so essential a salt in the constitutionof the serum, and as the supply of that substance in the foodis often very deficient, or altogether absent, how does theblood in such cases obtain it ? 1 I stated just now that thephosphate of potash, with two atoms of fixed base, was a saltTeadily decomposed, losing one atom of its potash under veryslight disturbing forces, and the action of chloride of sodiumis able to produce this change, at the same time that phos-phate of soda is formed, together with chloride of potassium;thus can be explained how phosphate of soda is producedin the blood of animals who do not take this salt in theirfood, but only phosphate of potash along with common salt.

The amount of chloride of potassium in serum is small. Intwo analyses which I made for the purpose of estimating thetotal amount of potash in the serum of healthy blood, theresults were as follow:-

The iron found in the ash is chiefly derived from thelisematosiu, and is then in the state of peroxide. A smallportion, however, exists in other parts of the blood, probablyas a phosphate.

Silica or silicic acid is also contained in very minute quan-tities ill the blood; it is left, after the ash has been treatedwith water and acids, as an insoluble residue. In the bloodof the fowl it has been asserted to exist in much larger pro-portions. The salts which exist in the blood are not correctlyshown by the ash obtained by incineration; for doubtlessmany salts, with organic bases, are contained in it, whichare decomposed, and carbonates formed; and the phosphates,with only one or two atoms of fixed base, are capableof decomposing these carbonates, and forming phosphates,with three fixed basic atoms. Again, as the organic portionof blood contains sulphur in an unoxidized condition, duringthe burning, sulphuric acid is formed, and hence the amountof sulphates are increased.

Extractive matters, <&c.&mdash;tVe have next to examine thosebodies which have hitherto been classed under the head ofextractive matters. If the serum of blood is first coagu-lated by heat, to separate the albumen, then treated withether, to remove the fatty matters, the remaining fluid,when evaporated to dryness, yields a yellowish mass,consisting of the salts of which we have just spoken,united to an organic matter named extractive. Berzeliusgives the following method of analyzing it:-The mass

should be first treated with anhydrous alcohol, which takesup a substance (alcohol extract) derived probably from thedecomposition of the .albuminous tissues; next with rectifiedspirit, (specific gravity, 833,) which dissolves out the chloridesof sodium and potassium, lactate of soda, and a mixture ofsubstances, called osmazome, possessing the odour of meat.The remaining mass contains carbonates, phosphates, and sul-phates, together with small quantities of animal matters,one of which is precipitated by tannic acid, and appears to bederived from the albuminous principles of the blood; anotherresembles albumen very much, and seems to be kept in solu-tion by the alkaline state of the serum, but is thrown downwhen the alkali is neutralized with acetic acid. The amount ofthese substances is differently stated by different observers,and they are generally estimated in analyses of theblood in conjunction with the salts. Lecanu found, in 1000parts of blood, 3.4 parts of these matters, of which 1.8 partswere soluble in spirit, and 1.6 parts only soluble in water.We cannot help observing, on looking at the older analysesof the so-called extractive matters of blood, that but verylittle light was thrown upon their nature by such examina-tions ; the same was the case, but a very short time since,with the extractives of flesh. A different mode of researchhas, however, now unravelled most of the obscurity ofthis subject, and we shall also find that out of the so-

called extractive matters of blood, we shall be enabled toeliminate many principles, the demonstration of whose pre-sence in the healthy blood tends to throw much light onseveral important functions in the animal body. A care-ful examination of them, both in health and disease, wouldwell repay any labour so spent, for it is here that we mustlook for abnormal matters which may be formed in theeconomy by disease, and for abnormal amounts of those sub-stances which, from the imperfect performance of the depu-rating organs, have been retained within the body, and which,in the healthy condition of habit, exist in mere traces.Much has already been done in this subject, but our know-ledge is still of a most imperfect description. In my nextlecture, I shall endeavour to make you more intimately ac-quainted with the nature of the substances classed under thishead.

Clinical LecturesON THE

GRAVITY AND TREATMENT OFGUNSHOT WOUNDS,

DELIVERED BY

M. VELPEAUAT THE "HOPITAL DE LA CHARITE," PARIS, AND OCCASIONED BY

THE GREAT NUMBER OF WOUNDED BROUGHT INTO THE HOSPITALAFTER THE CONFLICT OF FEBRUARY, 1848.

Translated, expressly for THE LANCET,

By VICTOR DE MERIC, M.D.,M.R.C.S.E.

LECTURE I.GENERAL CONSIDERATIONS ON GUNSHOT WOUXDS j PRIMARY AND

SECONDARY AMPUTATION.

GENTLEMEN,&ncaron;Two very distinct kinds of wounds resultfrom military encounters,-the first are incised or puncturedwounds, inflicted by bayonets, lances, swords, &c.; the second,gunshot wounds. The former have the same characters as

ordinary wounds produced by any pointed, cutting, or bruisinginstrument; but the latter belong to a totally di4.ferent class;and it is towards them that I desire now to direct your atten-tion, as the events which have just taken place afford us anopportunity of observing a great many cases of gunshotinjuries in our wards. These wounds may be divided intotwo orders-viz., those which implicate the limbs, and thosewhich injure any of the viscera. The gunshot wounds whichinvolve the limbs present likewise two species; the limb maybe shot completely through, or merely grazed. The injuryis, in the latter case, of very little moment; for it affects butone kind of texture-viz., the skin. Sometimes, however,the cellular tissue suffers also; but these wounds are nevercomplicated by any shattering of bone. The wounds whichextend through the whole thickness of the limb are lookedupon as simple, when the injury is confined to the soft parts;but they are called complicated when either bones, nerves,or vessels are injured; and these complications are, of course,extremely dangerous. A solution of continuity, affecting anervous trunk, is, however, less hazardous than the tearingor violent division of vessels, and the latter injury is againfraught with less danger than the fracture of bones, exceptin those cases where large arterial trunks are divided.

Ordinary compound fractures are much less serious than com-plicated gunshot wounds; for the instrument which inflicts theinjury in the latter case is round, destroys and disorganizesthe textures, turns them into a slough, which acts as a foreignbody, and mostly shatters the bone into several fragments.It is clear that before the healing process can be set up, themortified and sloughy parts, as well as the splinters of bone,must be eliminated by suppuration; but we know that exten-sive and prolonged suppuration is very likely to produceextreme exhaustion, sinuses, wide-spreading burrowing ofmatter, purulent absorption, and the hectic fever consequentupon it; so that a fatal issue in complicated gunshot woundsis very much to be apprehended. These wounds may, how-ever, present less danger according to the peculiar structureof the injured limb. If there are two long bones formingthe same, and one only be fractured, the danger is notconsiderable; but if the fracture is situated in the immediateneighbourhood of an articulation, the case is much moreserious. If the limb contain but one long bone, as the humerus,for instance, it may happen that the same be run through with-out a complete solution of continuity being established, or elm

4

the ball, instead of making a circular hole, may merely grazethe edge of the bone, and leave a sort of groove behind.These two latter cases are not looked upon as very hazardous.Fractures of the bones of the lower extremities are moreserious than those of the upper, the most dangerous being thefracture of the thigh. The reason of this fact is, that fracturesof the femur are almost always comminuted, first, on accountof the shape of the bone-secondly, because it is almostentirely formed of compact tissue, and generally shatteredinto a great many fragments. Another source of danger isthe deep situation of the femur, for the thick muscular masseswhich surround it suppurate abundantly, and allow extensiveburrowing of matter towards the pelvis or the knee.Having now disposed of the general considerations relative to

the sub-divisions and gravity of gunshot wounds, I will at onceenter upon the treatment which they require. The principalquestion to be decided in these cases refers to the adoption ofprimary or secondary amputation. Are we to take off thelimb at once, or delay the operation ? You are aware thatsurgeons do not answer this query in the same manner: some,with Boucher, (Annales de Chirurgie,) will tell you that im-mediate amputation is the only safe course; others maintain,with Faur, (ibidem,) that a subsequent operation is more I

advisable. Now, before attempting a solution of the problem,it will be well to consider the different stages through whicha person, upon whom a complicated gunshot wound is inflicted, iusually passes. The first is the period of stupor; this is the ’,result of the sudden shock which the nervous system, and, infact, the whole organism, experiences by the reception of thewound, the patient being mostly in a state of great excite-ment at the time. This period lasts generally from twenty-four ’to thirty-six hours, and is followed by the secondstage, which is the period of inflammatory reaction; thiswill appear towards the second or third day, and is ana-

logous to the period of elimination in burns. In alludingto burns I cannot help mentioning, en pm38ant, that ourforefathers firmly believed that gunshot wounds were

always complicated with severe burning. You are probablyaware that such is not the case; modern surgeons have fullyshown that this supposed complication is quite imaginary.Still, I must not omit to remark, that gunshot wounds, althoughthey never be complicated by actual burns, have neverthe-less several analogies with the latter. For the ball breaksdown the textures, not by the caloric with which it may becharged, but by its violently bruising effects, so that theresults are very similar to those of severe burns; and besidesthis resemblance, you may notice that the period of reactionin gunshot wounds is marked, like the same period in burns,bv the casting off of the sloughs.Now to return to the division into periods, which I was just

mentioning, I may go on by observing that the period of re-action has two phases; the first is characterized by swelling andinflammation, and extends over two or three days; and thesecond, by the formation of a slough, and an ichorous discharge.After this second period, or that of reaction, comes the thirdperiod, the principal character of which is suppuration. The

- primary or immediate amputation ought to be performed in theperiod of stupor; we should not wait until inflammation has setin, for it would continue on the stump, and go on invading theparts until it fastened upon the trunk. If from some considera-tion or other you do not amputate in the first period, it will beadvisable to put off the operation until the third stageviz., the period of suppuration-has set in. It is a very diffi-cult matter, indeed, to decide immediately, whether such agreat calamity as the loss of a limb should be incurred or not;and I do not think it possible for the surgeon to give a positiveopinion, on the receipt o. the injury, as to whether it is reallyimpossible to save the. limb. Faur was not ignorant of this,difficulty, and he came to the resolution of entirely rejectingimmediate amputations, for fear of cutting off a limb whichmight have been preserved. But Boucher, who was a warmadversary of his on this point, contended that Faur, by hisanxiety to save limbs, lost a great many patients. Cases ofgunshot wounds, complicated by fractures of the femur, arethe most puzzling of all; for the fractures, at first sight, do notseem very serious; but a sad experience has neverthelesstaught us that they almost always necessitate amputation-such is the opinion of Larrey, Percy, Gaultier de Glaubry, &,c.Surgeons engaged in civil practice, endeavoured, in 1830, toavoidamputation in cases of complicated gunshot wounds of thethigh. Out of eight or nine such cases, which I treated inmy wards at La Pitie, two recovered without amputation,three with secondary removal of the limb, and the rest died.Dupuytren and Lisfranc had also a few recoveries; and severalamputations.which were performed at the hospital o Saint

Cloud were followed by complete recovery. The consequencesof secondary amputations are, in fact, more favourable thanotherwise, because the patients escape the danger of theperiod of inflammatory reaction, which they have alreadygone through. But it so often happens, that an amputationwhich at first gave the very best hopes of a happy issue, be-comes unadvisable after a short time, on account of local dis-orders, or the weak state of the patient, that it is our boundenduty, in a great many cases, to have recourse to immediateoperation.When we are called upon to decide the question of

primary amputation, we should consider, first, the gravityof the wound, per se, and then the nature of the instrumentby which it was inflicted. Wounds made by bayonets, lances,swords, &c., hardly ever require immediate amputation; it isfor gunshot wounds that such an operation is almost exclu-sively required. During the conflict which a few days agobrought so many wounded into our wards, very few large pro-jectiles had been fired: you are aware that these will inflictinjuries of such a dreadful description as mostly to requireamputation without delay, for such wounds are always of avery serious nature. Deer-shot, small shot, &c., producewounds which very rarely necessitate the removal of a limb;but it is not so with musket-balls, for they are propelled with

such force and velocity, that they will divide vessels andnerves, and shatter bones into pieces. I need hardly remindyou, that an ordinary compound fracture, in the vicinity of anarticulation, often renders amputation imperative; but thenecessity of such a step becomes absolute and unavoidable, ifthe compound fracture be the result of a gunshot wound. Theimminent danger with which such wounds are fraught, were,by the older surgeons, attributed to some poison which hadbeen conveyed into them by the projectile. In the fifteenthand sixteenth centuries, it was universally believed that gun-shot wounds were irritated by some poisonous substances, andAmbrose Pare is the first surgeon who endeavoured to over-throw that erroneous opinion. I mentioned a few minutes ago,that gunshot wounds could not be considered as burns, butthat there was some analogy between these injuries; now Imust add that gunshot wounds also bear some resemblancewith actually poisoned ones. It is true that wounds inflicted bymusket-balls are not poisoned; this is of course evident enough,as we find no venomous substance either in powder or bullets;it is, nevertheless, a well-known fact, that gunshot woundssoon generate really venomous principles. These wounds,namely, consist generally in a sort of channel dug out in thevery thickness of the textures; the parietes of this channel

are bruised and triturated, and the channel itself contains adetritus and slough, which are floating in blood; this bloodremains stagnant under a temperature of about 90&deg;; confinedand hemmed in by disorganized tissues, it soon undergoes de-composition, gets putrefied, and becomes actually poisonous.If under such circumstances resorption should take place, itis clear that the system will be contaminated by these dele-terious principles, and the subsequent phenomena resultingfrom the stagnation of this noxious liquid sufficiently provethis to be the case. We should therefore not wonder thatthe surgeons of the fifteenth and sixteenth centuries shouldattribute the continued and intermittent fevers, the adynamia,the yellow tinge of the face and of the rest of the body whichmostly accompany gunshot injuries, to some poison conveyedinto the wounds.

It would then appear, from the foregoing considera-tions, that gunshot wounds are lesions of a very seriousnature, since they combine the characters both of burnsand poisoned wounds; and these two circumstances mightsuffice to induce the surgeon, in a great majority of cases, tohave at once recourse to amputation. But if the wound,already dangerous enough by being inflicted with a ball, becomplicated by the fracture of the bone, and this fracture besituated in the vicinity of an articulation, there is not a momentto be lost, and the removal of the limb should at once beeffected. I am now, gentlemen, going to operate upon a manwhose limb ought to have been taken off a few days ago, buthe refused to submit, and I am sorry to say that he is now ina very unfavourable condition. This poor man had his armfractured by a musket-ball on the memorable 24th of February,and we find this morning, (29th,) extensive sphacelus of theforearm. You remember that we recognised three periods inthe progress of gunshot wounds; I have to add, that betweenthe first and the second there is an intermediate one, whichis characterized either by haemorrhage or gangrene. Now,when dangerous haemorrhage occurs after the period of stupor,you should amputate at once, and not wait for the suppurativestage. If, in the same way, gangrene were to appear after

5

the period of prostration, you should not delay the operationan instant, for the swelling would soon prevent you altogetherfrom resorting to the knife, and you would thus lose the onlychance of saving your patient. I am bound to tell you, thatall surgeons do not agree with me in this respect; many thinkthat no amputation should be performed with traumatic gan-grene, before the latter is distinctly limited. Now I am not

going to await this said line of demarcation in this case, forthe gangrene is ascending very rapidly; it would before longinvolve the shoulder, and death soon close the scene. I amtherefore going to operate, repeating with Celsus, Meliusanceps quam nullum remedium." I am much encouraged tofollow this line of practice with this man, by the good results ob-tained in the case I operated on the day before yesterday. Thatunfortunate individual had his leg and knee shockingly shat-tered by a ball on the 24th of February; he refused the imme-diate amputation, and the leg two days after was extensivelysphacelated; I therefore took off the limb early on the 27th,and the man is doing well. I did not use chloroform for thatpatient, nor shall I take advantage of this anmsthetic agentfor the patient who is about to be brought in, because thechloroform evidently depresses the nervous system, and asgreat prostration always exists in patients who have receivedgunshot wounds, it is advisable to refrain from any anaestheticmeans.

Hospital Reports.ROYAL FREE HOSPITAL.

Reported by WEEDEN COOKE, Esq., late Resident-Surgeon.

’THE NEW FOOT-OPERATION.-EXCISION OF THE ANKLE-JOI;.;T, ANDTHE ENTIRE REMOVAL OF THE OS CALCIS AND ASTRAGALUS.-

RECOVERY.

W. B-, aged twenty-three, a tailor, of dark cO"1plexlOn,pale and emaciated, was admitted into the Royal Free Hos-pital, December 20th, 1847, under the care of Mr. ThomasWakley. The history he gives of his case is, that twelve orthirteen years ago an abscess formed at one side of the anklewithout any apparent exciting cause; this broke, and con-tinued open for two years; it then got well, and continued so(the ankle all the time being weak) until ten months since,when he sprained the ankle whilst wheeling a truck; in-ilammation was set up, and, in a few weeks, an abscess whichhad been forming, burst. At this time he became a patientat St. George’s Hospital, where he was told that the boneswere diseased. Having remained there for nine weeks, hewas sent to Margate for sea-bathing, which he continuedfor four months, during which time a portion of bone, thesize of a hazel-nut, came away, and he was then greatly re-lieved from the pain, which had previously been very severe.At the termination of these four months he returned to hisemployment for a month, but finding his foot again becomingworse, he obtained admission to the Brighton Hospital,where he remained six weeks, and there amputation of the legwas proposed to him: to this he objected, and coming totown, he applied at the Royal Free Hospital.Dec. 21st.-On examination of the diseased member this i

day, the integument all over and around the left heel andinner ankle was found to present an unhealthy, purplishaspect, and there were three openings, from which a largequantity of ichorous fluid exuded. Two of these openingscorresponded with the astragalus and os calcis, and a probeintroduced into them entered the substance of the bones;the third opening commuiicated with the calcaneo-astragaloidarticulation. It was evident that the os calcis and astragaluswere in a state of caries; but, after a careful examination,Mr. Wakley was led to believe that the internal parts of theankle-joint were not implicated in the disease. The man hadbeen suffering for some time under constitutional disturbance,arising out of the state of his foot, and it was apprehendedthat hectic fever would soon supervene and destroy him.Symptoms of hectic had already appeared.As the patient expressed a wish to be enabled to retain his

foot, and had strongly objected to its removal, either belowthe knee or at the ankle-joint, Mr. Wakley determined todissect out the diseased bones-namely, the os calcis andastragalus,-believing that he could effect this object, andleave the patient an useful and efficient member for the pur-pose of progression. On making this proposal to the patienthe immediately assented, and was desirous that the attemptshould be made.On December the 27th, 1847, the man having been placed

on the operating-table, Mr. Robinson administered the chlo-roform, and a complete state of insensibility was soon induced.Mr. Wakley was ably assisted in the operation by Mr. ErasmusWilson, and by Mr. Gay, his colleague. The diseased foot (theleft) having been drawn forwards so as to be free of the opera-ting-table, Mr. Wakley, standing directly in front, and holdingthe scalpel in his left hand, made an incision from the promi-nence of the internal malleolus, backwards and downwards, tothe middle of the heel. A similar incision with the right handwas then made from the external malleolus, downwards and

backwards, to join the foregoing. A third incision was nextcarried along the edge of the sole, from the middle of the firstto a point opposite the astragalo-scaphoid articulation; and afourth on the opposite side of the sole, from the vertical inci-sion to the situation of the calcaneo-cuboid joint. Theselatter incisions enabled the operator to make a flap of abouttwo inches in length from tha under part of the sole. In thenext place a circular flap of integument was formed betweenthe two malleoli, posteriorly, the lower border of the flapreaching to opposite the insertion of the tendo-Achillis. Thisflap being turned upwards, the tendon was cut through, andthe os calcis having been disarticulated from the astragalusand cuboid bones, was removed, together with the integumentof the heel included between the two incisions. The lateralligaments connecting the astragalus with the tibia and fibulawere now divided, and the knife was carried into the joint oneach side, extreme care being observed to avoid wounding theanterior tibial artery, which was in view. The astragalus wasthen detached from the soft parts in front of the joint, andfrom its articulation with the scaphoid bone, and the malleoliof the tibia and fibula were removed with the bone-nippers.The only artety requiring ligature was the posterior tibial.During the few minutes the operation occupied, the patientdid not manifest the slightest symptom of pain or uneasi-ness.